Claim Form (Health Insurance)
A Claim Form is a mandatory document you submit to your insurance company or TPA (Third Party Administrator) to initiate a claim for hospitalization, either for cashless or reimbursement.
It is used to:
Declare your hospitalization or treatment details
Request payment or reimbursement
Provide personal and policy information to the insurer
PART A – To Be Filled by the Insured / Policyholder
Policyholder Details
Name:
Policy No.:
Company Name (if corporate group policy):
Contact No.:
Email ID:
Patient Details
Name:
Relationship with Policyholder:
Gender:
Age:
Date of Birth:
Occupation:
Hospitalization Details
Name of Hospital:
Date of Admission:
Date of Discharge:
Reason for Hospitalization (Diagnosis):
Treatment Given:
Claim Type
☐ Cashless
☐ Reimbursement
Bank Details (for Reimbursement)
Account Holder Name:
Bank Name:
Account No.:
IFSC Code:
Cancelled Cheque Attached: ☐ Yes ☐ No
Declaration & Signature
I hereby declare that the information provided is true and correct.
Signature of Policyholder:
Date:
PART B – To Be Filled by the Hospital
Hospital Name & Address
Hospital Registration No.
Nature of Admission (Planned / Emergency)
Diagnosis (Final)
Treatment Given
Doctor’s Details and Signature
Documents to Attach with Claim Form
Discharge Summary
Bills & Receipts
Diagnostic Reports
Prescriptions
Health Card Copy
ID Proof
Cancelled Cheque (for reimbursement)
Important Instructions for Filling the Claim Form
Please read the claim form carefully before you begin. This ensures smooth processing and helps avoid unnecessary delays or rejections.
Before You Start:
Write your Employee ID, Contact Number, and Intimation ID clearly at the top right corner of the form.
Mandatory Fields to Fill:
Policy Number
Insurance Card ID Number
(Unique ID given by the TPA — found on your health card)
Name of the Insured
Include address and contact details
Corporate/Employer Name and Employee Code
(For group/corporate insurance policies)
Patient Details
Name
Date of Birth
Relationship with the employee
Claim Type
Tick the appropriate option (Cashless / Reimbursement)
Mention:
Date of Admission
Date of Discharge
Hospital Name, Address, and Contact Details
Details of Illness / Injury / Diagnosis
Reason for hospitalization/treatment
Claim Amount Details
Mention the total amount claimed
Add a bill-wise breakup with bill numbers
Attach All Original Documents
As mentioned in the claim form (discharge summary, bills, reports, etc.)
Signature of the Claimant
Include Place and Date
After Filling the Form:
Submit the completed and signed claim form along with all mandatory original documents to the TPA or insurer.
Note: Incomplete forms or missing information may lead to claim delays or rejections. If you need help at any step, feel free to reach out to your HR SPOC or insurance support team.